Evidence for the timing and frequency of monitoring chronic conditions in primary care is often of low quality or absent. Recently, a methodology based upon repeated measures of monitoring tests has been developed to evaluate monitoring strategies which differ by frequency and the length of interval. In studies using this approach, it has been shown that there is potential for substantial over-detection and over-treatment through routine monitoring. The aim of this thesis was to extend the existing methodology to outcomes with highly skewed distributions and tests that are interpreted as dichotomous or categorical states. These methods were applied to find evidence for the intervals of monitoring for microalbuminuria in people with type 1 diabetes and screening for diabetic retinopathy. Statistical models were used to describe the progression of albuminuria and retinopathy and estimate the rates of false positive and false negative tests over time. Simulation was then used to create hypothetical cohorts of people being monitored and screening at different frequencies and for different baseline risk. The impact of changing the timing of tests within the programme was measured and evaluated. The basic framework of the methodology can be usefully extended to tests that have categorical outcome or highly skewed distributions. More frequent monitoring of microalbuminuria in people with type 1 diabetes, and more frequent screening of diabetic retinopathy leads to disproportionate numbers of false positive results and potential over-treatment or referral to specialist services. As with any other clinical intervention, monitoring and screening intervals should be based upon solid evidence. Monitoring for microalbuminuria and screening for diabetic retinopathy less frequently would reduce the rates of false positives tests but the implications of less surveillance need further investigation.

Thesis advisor: Susan Kelly-Weeder / Background: Addressing childhood obesity requires a multidisciplinary approach. School based BMI screening and referral provided an opportunity for school nurses (SNs) and pediatric primary care physicians to collaborate. Understanding the capacity to collaborate, as well as the barriers and benefits, help to support interprofessional care. Purpose: The purpose of this investigation was to determine SNs’ and pediatric physicians’ attitudes toward collaboration as well as the presence of successful collaboration proposed in the Four Dimension of Collaboration Model (FDCM). Methods & Sample: An exploratory, cross-sectional mixed methods study of SNs’ and pediatric physicians’ attitudes and practices regarding collaboration was conducted using a combination of web-based and mailed survey instruments utilizing both open and closed-ended questions. One hundred and fourteen school nurses and sixty-three pediatric physicians completed the study. Results: While SNs and physicians both reported high scores on the Jefferson Scale of Attitudes toward MD-RN Collaboration (JSAC) indicating a positive attitudes toward physician – nurse collaboration; SNs scores were significantly higher than physician scores (55.05 + 3.30 v 52.42 + 5.74, p = .001). A regression model identified that physician’s age, community location, and having a moderate percentage of obese patients within their practices were associated with positive (age) and negative (community and moderate percent obese patients) effects on attitude toward collaboration. Providers’ responses indicated deficits throughout the FDCM. Dimension indicator, “mutual acquaintanceship” indicated that 37% physicians did not know any SNs. Similarly, 24% SNs reported that they did not “trust” local physicians to listen to their concerns. Qualitative analysis indicated the myriad of challenges faced by both providers. Benefits and barriers were similar for SNs and physicians; however, their experiences suggested a lack of mutual knowledge. Conclusions: Collaboration around childhood obesity is a unique struggle due to its multifaceted nature. School nurses and physicians showed positive attitudes toward collaboration; however, their capacity to act was limited. School nurses and pediatric physicians recognized the value of interprofessional collaboration recommending improvements to the current system. / Thesis (PhD) — Boston College, 2017. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

PhD, Faculty of Health Sciences, University of the Witwatersrand / Background: Chronic diseases have increased worldwide. Despite the significant advances in medical science, the management of chronic diseases continues to be poor. To meet this challenge, we need to try to implement existing chronic illness models of prevention, early detection, and risk factor management. This is achievable in part by linking primary health care clinicians, such as primary health care nurses (PHCNs) and hospital-based medical specialists. This study evaluated a ‘real life’ chronic disease outreach program (CDOP), which assisted PHCNs with the early detection and management of chronic illnesses known to cause chronic kidney disease (CKD) and cardiovascular disease (CVD). PHCNs are critical in the management of chronic illnesses but they require ongoing support of and links with specialists. This will ensure that current guidelines reach the people receiving primary health care (PHC) and detection of those needing referrals. Aims: The study aimed to determine if CDOP was an effective method for the early detection and management of diabetic and hypertensive patients at high risk for complications like stroke, ischaemic heart disease and CKD. It also aimed to evaluate the PHCNs’ knowledge and motivation, and to elucidate the challenges facing the current health system in the management of patients with chronic conditions. Methods: Patients at risk for complications were enrolled for increased monitoring and clinical support and management, at 20 clinics in Soweto, South Africa (SA). CDOP used a paper-based support and patient care system, modelled on the Wagner Chronic Illness Care Model (CICM). The components for evaluation included: (i) Focus on monitoring functional and clinical outcomes (ii) Health system interventions, such as increased ‘decision support’ and the development of a ‘prepared motivated health care team’ and (iii) Enhancing PHCNs’ knowledge and motivation. The evaluation followed the various elements of the Wagner CICM, as well as drawing on the WHO Innovative Care for Chronic Conditions (ICCC) Framework. A cohort analysis of functional and clinical outcomes in enrolled patients was conducted. PHCN knowledge and motivation was assessed through self administered questionnaires. Health worker knowledge was evaluated through the use of case scenarios and multiple choice questions. On the theme of health worker motivation, Franco’s model, with Penn-Kekana’s adaptation, was used to develop the questions and analyse diary recordings. Diary recordings of PHCNs and meetings with regional and provincial health managers’ discussions were collected by CDOP staff during follow-up focus groups and feedback meetings. Diaries were analysed thematically. The CDOP evaluation is thus a triangulated analysis of clinical and functional outcomes, diary recordings, and the self-administered questionnaire. Results: The CDOP ran from 2003-2006, during which time 618 patients (61% females, 39% males) deemed at risk of CKD or CVD were enrolled; 55% had uncontrolled hypertension (HTN), 45% DM with HT and/or proteinuria. Patients were followed for 2 years. In total, 108 patients completed 2 years of follow up, most of whom were referred for specialist support (n=69, 11%), more intensive medication regimes or because were not available in the PHC system. Most did not require referral (515, 82%), 35 (6%) were referred but never arrived at the hospital and 6 (1%) died. Twelve percent had advanced CKD, 2% required dialysis, 6.9% required medications not available to primary care clinics, and 1% died. As a tool to detect those needing referral, the program was successful. The sensitivity and specificity for detecting those needing referral was 95% and 100%, respectively.. However, although PHCNs were able to detect high risk patients, not all those referred arrived at the hospital. Hypertension, blood glucose, cholesterol and proteinuria control significantly improved in those followed (p<0.01) over 2 years, but no improvement was noted with weight control. Importantly, proteinuria and kidney function, in patients with static stable renal function, measured by estimated GFR equations and urine dipstick or albumin creatinine ratio (ACR), did not worsen significantly. Of the remaining 510 patient enrolled but not followed up, 213 (35%) were reabsorbed into the routine clinics, and a further, 123 (20%) of patients enrolled were lost to follow up completely. The diary recording thematic analysis revealed the problem of poor patient follow up, attributed to the poor existing health system in the clinics, competing demands on PHCNs, staff shortages, high staff turnover, and the low motivation and morale of clinicians. The analysis of the health worker questionnaire showed improved motivation and statistically better knowledge in those PHCNs involved with CDOP compared to those who were not exposed to the program (p<0.0034). Conclusions: CDOP was successful in supporting PHCNs, detecting patients with advanced disease and ensuring their early referral. Such programs are able to correctly detect people with disease, but this is dependent on the health and program systems being intact. It also improved patient risk factor control in the sub-set of referred patients and impacted on PHCNs’ existing knowledge and motivation for caring for patients. Its weaknesses were related to the poor existing health systems and infrastructure, and the poor integration of chronic illness care in the region. The PHC clinics had poor follow up compared with that in the hospital setting. The study also revealed an overworked, poorly supported, and frustrated primary health care team. This was despite the fact that the PHCNs were willing and motivated to deliver a good service.

Identifying people with advanced illnesses whose health is deteriorating, assessing their needs and planning care proactively with them are healthcare priorities given the demographic trend of ageing populations in the UK and internationally. Over the past 10 years (2004-2014), I have led a series of research studies that have made an important academic contribution to improving palliative care services for patients with heart disease and advanced multimorbidity. My first paper reported secondary analysis of data generated from a qualitative study of the illness and care experiences of patients with advanced heart failure. This work used innovative, qualitative research methods to explore and understand patient, carer and health professional perspectives over time. My second study then evaluated whether health and social care services were configured and delivered in response to the needs of people with heart failure and their families. This led me to recommend an anticipatory care framework which integrated a palliative care approach with other aspects of treatment and care. Around this time, advance care planning (planning ahead to facilitate end-of-life care aligned with people’s goals and preferences) was being strongly advocated by NHS health policy makers despite limited research in the UK. For my third study, I evaluated an evidence-based, educational intervention for general practitioners while also exploring barriers and facilitators to advance care planning in primary care for patients with cancer or other advanced conditions. It was becoming increasingly clear that failure to identify people with deteriorating health and a high risk of dying in a timely way was a major barrier to more effective palliative care. The problem was greatest for patients with non-malignant conditions whose illness trajectory is much less easy to predict than in cancer populations. I therefore started to research and develop a new clinical tool designed to prompt early, proactive patient identification in routine clinical practice – the Supportive and Palliative Care Indicators Tool (SPICT). My fourth research paper reported an evaluation of the SPICT in a mixed-methods study in a large tertiary care hospital. The SPICT was then used to identify people with multimorbidity for my fifth study, a longitudinal exploration of patient and carer experiences of hospital admission and ongoing community care. In my final paper, I drew on my previous research and combined this with well-developed approaches to timely identification and effective communication. I described the design of a successful pilot randomised trial of future care planning with people who had advanced heart disease and their carers. This thesis presents a critical review of these six research studies setting them in context and demonstrating the impact they have had in ensuring that high quality research evidence informs current and future developments in palliative care policy and clinical practice.

yes / This systematic review of reviews aims to investigate how brief interventions (BIs) are defined, whether they increase physical activity, which factors influence their effectiveness, who they are effective for, and whether they are feasible and acceptable. We searched CINAHL, Cochrane database of systematic reviews, DARE, HTA database, EMBASE, MEDLINE, PsycINFO, Science Citation Index-Expanded and Social Sciences Citation Index, and Scottish Intercollegiate Guidelines Network from their inception until May 2015 to identify systematic reviews of the effectiveness of BIs aimed at promoting physical activity in adults, reporting a physical activity outcome and at least one BI that could be delivered in a primary care setting. A narrative synthesis was conducted. We identified three specific BI reviews and thirteen general reviews of physical activity interventions that met the inclusion criteria. The BI reviews reported varying definitions of BIs, only one of which specified a maximum duration of 30 min. BIs can increase self-reported physical activity in the short term, but there is insufficient evidence about their long-term impact, their impact on objectively measured physical activity, and about the factors that influence their effectiveness, feasibility and acceptability. Current definitions include BIs that are too long for primary care consultations. Practitioners, commissioners and policy makers should be aware of this when interpreting evidence about BIs, and future research should develop and evaluate very brief interventions (of 5 min or less) that could be delivered in a primary care consultation. / Citation sent on from Donna. Emailed Laura Lamming for final draft 16/03/2017 -sm

Successful implementation of the American Academy of Pediatrics evidence-based practice guidelines for ADHD management in primary care settings is challenging. Despite widespread use of these guidelines and the adoption of strategies to overcome barriers to care, no research has looked at how providers spend their time in managing ADHD and how this relates to the feasibility of practice guidelines in community settings. The present study aimed to assess pediatricians’ self-reported experiences in using the AAP guidelines for ADHD management and barriers to using an evidence-based approach, especially related to time demands. Five pediatricians from five pediatric primary care settings were interviewed on their experiences in ADHD management. Time demands was shown to be related to on-site behavioral health services and innovative scheduling strategies. Implications for primary care practice and future research are discussed.

The present study sought to examine optimism and hope as predictors of suicidal behaviors (viz., suicide ideation and suicide attempt) in a sample of 179 adult primary care patients. Furthermore, we aimed to determine if the combination of hope and optimism would account for additional variance in the prediction model for suicidal behaviors among this population. In this cross-sectional study, participants completed measures of hope (viz., agency and pathways), optimism, and suicidal behaviors, as well as a series of demographics questions. Hierarchical regression analyses were conducted to test the aforementioned hypotheses. Results indicated that hope and optimism were both significant and unique predictors of suicidal behaviors among adult primary care patients. However, the hope-by-optimism interaction terms were not found to be significant. Some implications of the present findings are discussed.

The present study examined the role of vitality as a mediator of the association between dispositional hope and quality of life (QoL) (namely, physical health, psychological health, social relationships, and environment) in a sample of 101 adult primary care patients. Vitality was found to fully mediate the relationship between hope and physical health, social relationships, and environment. In addition, vitality was found to partially mediate the association between hope and psychological health. The present findings are consistent with a model in which vitality represents an important mechanism through which hope affects QoL in adults. Accordingly, these findings point to the importance of fostering both hope and vitality in efforts to promote positive QoL in adults.

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